The crotchets of Sir Jonathan Hutchinson, father of routine male circumcision

Anything may be proved by statistics, and … anything may be seen by the aid of a microscope. … Upon this subject of epidemics we want facts and faithful records.

— Quaesitor, Lancet, 6 January 1855

For every problem there is a neat, simple solution, and it is always wrong.

— H.L. Mencken

Until very recently Jonathan Hutchinson was familiar only to a few medical historians as the surgeon who did not shrink from recommending castration in chronic cases of masturbation. If he was remembered by medical science it was as the closest thing to an authority on venereal disease nineteenth century England managed to produce: the Oxford Companion to Medicine pays tribute to him as a medical polymath who gave the world "Hutchinson’s triad" – three signs by which congenital syphilis could be recognised in young children. (1) At a time when no effective treatment was available the value of such a diagnosis to the child was slight, but it seemed evidence of the medical profession’s insight into the mysterious world of disease, and at least warned parents that they should start saving for the funeral. It was not the sort of physiological discovery or therapeutic breakthrough on which enduring reputations are normally built.

Surprisingly, however, the early work of Hutchinson has recently been cited by an international group of (mainly Hispanic, but largely US-trained) researchers, led by Dr Xavier Castellsague, who seem to be intent on reviving the old theory that the male foreskin is a major risk factor for cervical cancer in women. (2) This idea was first aired by enthusiasts for mass circumcision in the 1930s, when the natural preputial secretions were imagined to be the causative factor. The association was disproved for developed nations by many studies since the 1960s, (3) but this has not prevented Xavier’s team from claiming that the link is valid for Third World countries, or at least among poor and ignorant populations with high birthrates, a lot of smoking and malnutrition, poor hygiene, a high incidence of sexual promiscuity (especially with prostitutes) and a low level of condom use – all minor factors, however, compared with those troublesome foreskins which are the real cause of the problem, or a least a cause which is easily fixed. A virus (HPV) has been identified as the infectious agent, but the scent of quackery lingers.

The researchers have hailed Hutchinson as their precursor on the basis of his report, in 1855, that circumcision might prevent syphilis – and quite appropriately, for he did indeed claim this, and more. Among his many other gifts to medical understanding were the convictions that Jews were immune to syphilis; circumcision of male infants was necessary to discourage masturbation and promote continence; contraception was morally objectionable and physically harmful; and leprosy was a form of tuberculosis, caused by eating bad fish.

(Sir) Jonathan Hutchinson (1828-1913) is an unlikely subject for positive revaluation. A reserved and gloomy Quaker whose watchword was self-denial, he was a puritanical workaholic even by Victorian standards. His youthful diary shows him rising before dawn each day to study his medical books and read the Bible: his text for 28 December 1848 was Hebrews XI, "a most eloquent and beautiful chapter", to which he responded: "My supplications were poured forth at the footstool of almighty power for an increase of faith, lest, privileged to live under a great and glorious covenant of mercy, I might by any means fall short of the better things which God has provided for us". He was only twenty. (4) Other favourite readings were the sufferings of Job and St Paul’s Epistle to the Galatians – the one in which he reproaches them for continuing to practise circumcision, forgetful that Christ’s sacrifice had made such fleshly signs of righteousness unnecessary. Hutchinson seems not to have approved of Paul, however, but to have agreed with the learned Dr Copland, author of the widely read Dictionary of practical medicine, that there would be much less masturbation among boys if the early Christians had not dropped the Judaic rite. (5) His own reasons for advocating routine circumcision owed more to moral sentiment than medical science, though he did his best to give them a statistical gloss.

In his practice at the Metropolitan Free Hospital, Hutchinson recorded the incidence of venereal cases among his Jewish and non-Jewish patients during 1854 and came up with the following table:

Venereal cases

Gonorrhoea

Syphilis

Non-Jews

272

107 (39.3%)

165 (60.6%)

Jews

58

47 (81%)

11 (19%)

On the basis of these figures he claimed he had demonstrated a conclusion "long entertained by many surgeons of experience": that "the circumcised Jew is … very much less liable to contract syphilis than an uncircumcised person", and the reason was obvious: circumcision rendered "the delicate mucous membrane of the glans hard and skin-like". Hutchinson provided no elaboration of his reasoning as to why a damaged ("hard and skin-like") glans should provide this protection, nor what non-injurious alternatives might be recommended if it really did, but he showed no such reticence when it came to the clinical implications. Given these facts, Hutchinson suggested that it was

probable that circumcision was by Divine command made obligatory upon the Jews, not solely as a religious ordinance, but also with a view to the protection of health. … One is led to ask, witnessing the frightful ravages of syphilis in the present day, whether it might not be worthwhile for Christians also to adopt the practice. (6)

It was a flimsy foundation on which to erect such an ambitious therapeutic edifice. All his observations showed is that, while non-Jewish venereal cases had more syphilis than gonorrhoea (60.6 to 39.3 per cent), Jewish cases had more gonorrhoea than syphilis (81 to 19 per cent). Although Hutchinson insisted that the high level of gonorrhoea among the Jews proved that less promiscuity could not have been the reason for the difference, the statistics revealed nothing about the relative susceptibility of cut and normal men to venereal infection, and could as well be cited to show that circumcision increased the likelihood of getting gonorrhoea. By comparing the syphilis cases with the Jewish and non-Jewish population of London in the 1850s it is actually quite easy to manipulate these figures in such a way as to suggest a conclusion radically different from that reached by Hutchinson. In 1851 London held about 2,360,000 people, (7) and in 1858 there were about 36,000 Jews in England, of which two thirds (24,000) lived in the metropolis. (8) Taking Hutchinson’s patients as a proportion of the respective populations, we arrive at the following table:

Syphilis cases

London population

Rate of syphilis

Non-Jews

165

2,336,000

0.007%

Jews

11

24,000

0.046%

It can readily be seen that circumcised Jews had a rate of syphilis many times higher than their gentile neighbours. The point is that you can make the rate of syphilis anything you like, depending how you select the catchment population against which to calculate the proportion.

Nobody would take these extrapolations seriously, yet they are scarcely more illegitimate than the implications drawn from Hutchinson’s own figures, which were taken so seriously that for the next century they were regarded as the "hard data" needed to prove the health-giving value of pre-emptive foreskin amputation. In 1900 E. Harding Freeland cited them to prove that "circumcision of every male in infancy" would reduce the incidence of syphilis by 49 per cent. (9) In 1914 Abraham Wolbarst relied on them to support his call for "Universal circumcision as a sanitary measure". (10) As late as 1947 Newsweek praised Hutchinson as the first to discover that "syphilis and gonorrhoea were uncommon among Jewish people" and asserted that circumcised men "are not likely to contract venereal disease". (11) That nobody until the 1890s even questioned Hutchinson’s figures (12) is an indication of how strongly the tide of medical opinion was running in favour of circumcision: any evidence would apparently do.

Hutchinson’s enthusiasm for circumcision increased as he grew older. In 1890 he issued "A plea for circumcision" in which he insisted that "the superior cleanliness of a Hebrew penis" was in itself an argument for the amputation of the foreskin: "It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation and adds to the difficulties of sexual continence. It increase the risk of syphilis in early life, and of cancer in the aged." (13) Later that year he published a further article in which he urged circumcision as a disincentive to masturbation and regretted that public opinion would not permit the introduction of castration as a more radical approach to the problem. (14) Three years later he advised the circumcision of baby boys as "imperatively required whenever the prepuce is unusually long and contracted", but added that the surgeon should also "avail himself of every possible opportunity of inducing parents to have their male children circumcised", an operation with "great advantages" on which he provided detailed procedural instructions.

Although he stated that the surgery had "no drawbacks whatever", he warned that haemorrhage was a danger and that "many children have died after the operation as a consequence of carelessness in this matter." (15) He seems to have felt it was better to die quickly from uncontrollable bleeding as an infant than to waste away slowly from the effects of masturbation or syphilis in adulthood.

Hutchinson returned to the topic at the turn of the century with a lecture, "The advantages of circumcision", widely reported in British and US medical journals. His strongest argument in favour of "the general practice of circumcision" was that it "would reduce the prevalence of syphilis", in support of which opinion he recalled his statistics from 1854, "which proved" that, while gonorrhoea was as common among Jews as Christians, syphilis was "much less frequent". This fact showed that it was not superior morality which gave Jews their "comparative immunity", but some "adventitious advantage" which could only be "the absence of the prepuce"; and not surprisingly, for it would be "difficult to contrive an appendage more likely to facilitate the implantation of the syphilitic virus". Hutchinson assured the public that no measure for the prevention of syphilis was as efficient as circumcision, but he made no mention of condoms (mass produced and available since the 1880s), (16) probably because he "regarded with disgust artificial means to prevent having children. Such practices are prejudicial to both moral and physical health." (17) Indeed, he seems to have held a deeply puritanical objection to non-procreative sex:

Measures, such as the inspection of prostitutes, have a collateral influence prejudicial to morality. Professedly making irregular sexual intercourse less dangerous, they possibly increase its amount to an extent which more than counterbalances their supposed advantages. They are also injurious to the sense of decency, to say nothing of modesty, and detrimental to the moral conscience of a community. It is no so with circumcision. Effected in early infancy, and with other avowed objects [that is, curbing masturbation] it would silently become the means of preventing on a large scale the prevalence of a loathsome and misery-producing disease. The extent to which this diminution of risk might tend to increase sexual folly would probably be infinitesimal. (18)

In other words, in controlling syphilis circumcision was preferable to condoms or health checks because it would discourage pre- and extra-marital sex. The value of the operation would be enhanced by its effect in diminishing the sexual appetite:

The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of the act and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful. (19)

Such a frank acknowledgment of the effect of circumcision on sexual function showed a greater sense of realism than some of Hutchinson’s other pronouncements on disease.

Notable among these was his obstinate belief that leprosy was caused by eating rotten fish. He first wrote a paper on the subject in 1863, and even the discovery of the guilty bacillus in 1874 did not turn him from his path: Why was leprosy associated with coast-dwelling peoples? Why was it common in Europe in the Middle Ages, when everybody ate fish on Fridays, but rare today, when the practice was less strictly followed? Neither the public nor his colleagues were convinced, so in 1906 he wooed them with a book called On leprosy and fish eating, in which he not only amassed the statistical evidence, but demanded strict government regulation of the fish industry as the only effective means to address the problem. Among his scientific claims were that leprosy could be cured by abstention from fish and the use (both internally and externally) of "Chaulmoogra oil" (whatever that was); and that the bacilli of tuberculosis and leprosy were "differentiated forms of the same organism". (20) Hutchinson was not able to produce statistics as telling as those which proved that circumcision conferred protection against syphilis, and doctors had nothing to gain from closer supervision of the fish trade, so the "Fish – control of leprosy regulations" did not emerge to complement the public health advantages of routine infant circumcision, and a startling epidemiological insight faded quietly away.

As it turned out, Hutchinson’s theories of syphilis prevention were as wrong as his ideas about leprosy. Gradually it was realised that any reduced incidence of venereal disease among Jews was the result of cultural and lifestyle factors: the quarantine effect of segregation and a low level of sexual promiscuity. The position was put clearly by Ephraim Epstein, a Russian Jew practising as a physician in Cincinnati, USA, who commented in 1874:

In common with others … once I believed that circumcision affords a protection against venereal [diseases], but my practice in Vienna … and in this country since 1862 persuaded me fully to the contrary. The apparent immunity which the Jews of Russian and European Turkey … seem to enjoy from venereal diseases arises from their greater chastity and the practice of early marriage. … The singular pre-eminence of the Jews in health is a mere fiction, propounded either by those who are not acquainted with the Jewish race in this country, or by certain Jewish enthusiasts who have a special axe to grind. (21)

It was also realised (as even Hutchinson had admitted) that the operation, in the days before aseptic surgery, actually infected many babies and children with syphilis, tuberculosis and other diseases, not to mention ordinary gangrene. (22) Circumcision played no role in the eventual conquest of syphilis, which was tamed by growing use of screening and early identification, condoms, Metchnikoff’s ointment and Salvarsan, and defeated in the 1940s by penicillin. (23)

Hutchinson’s broad theory of disease causation belonged firmly to the eighteenth century: a mixture of divine providence and human error. He agreed with Thomas Sydenham (an English medical writer of the seventeenth century) that "of acute diseases, God is the cause; of chronic ones, ourselves". (24) Yet there is not such a yawning gulf between his approach and that of agenda-driven researchers like Dr Castellsague’s team, both of which know what they want to find and are inclined to ignore contradictory or confounding data. Hutchinson all but admitted that he sought evidence only for what he already wanted to prove: as he confessed in 1890, "I had long ago adopted the rule, to believe only what I thought likely to be true". (25) Following this principle, it would be impossible to discover anything that would shake his opinions. His decision to collect statistics on the incidence of VD among his Jewish and non-Jewish patients arose from his certainty, "long entertained by many surgeons", as to the prophylactic value of an early circumcision; his aim was to support the opinion he had "long shared" with his friend Mr Forster that infants with tight foreskins should always be circumcised. (26)

Commending Dr Castellsague’s study, and welcoming the clinical implications, the editorial writers of the New England Journal of Medicine affirmed that it had merely verified what they had "long … suspected": that (male) circumcision reduced the risk of cervical cancer. (27) The deeper truth is that the NEJM has been sniping at the foreskin for decades, deplores the decline of routine male circumcision in the USA and is very annoyed with the American Academy of Pediatrics for changing its policy in 1999. During the nineteenth century (as the Boston Medical and Surgical Journal) it regularly published articles like "Seminal weakness: Castration" (Vol. 29, 1843), "Insanity cured by excision of the external organs of generation" (Vol. 32, 1845), "Surgical treatment of hopeless cases of masturbation and nocturnal emissions" (Vol. 109, 1883), and "Excision of the clitoris as a cure for masturbation" (Vol. 66, 1862). Its latest attack on the male body is quite in accord with its finest traditions. Why, indeed, would you single out a certain part of the body for investigation unless you wanted to find evidence for its guilt in some wrongdoing? Reading the NEJM and its colourful press release, you would think that the cause of cancer was the foreskin, not a virus.

And why the sex discrimination? Doctors are not blaming women for infecting men with HPV, but where else do they get it from? If the foreskin provides a nest for the virus, so does the clitoral hood and the folds of the labia in females; perhaps routine circumcision of women would reduce the incidence of HPV infection and penile cancer in men. Because western doctors now regard amputation of any part of the female genitals as mutilation, however, they no longer have any interest in exploring this intriguing therapeutic possibility, and they do not seek associations between normal female anatomy and risk of disease.

It is different in the Islamic cultures which practise various forms of female circumcision, where doctors and religious leaders make similar claims about its benefits for women’s health.(28) An Egyptian Muslim cleric who overturned a government ban on female circumcision in 1997 not only thanked God for preserving a religious requirement handed down by mothers and grandmothers for fourteen centuries, but stated that the operation protected the nation from AIDS by reducing promiscuity. (29) In explaining the link between circumcision and disease control in behavioural rather than anatomical terms, the priest showed a better understanding of the epidemiology of STDs than many medical researchers. It would seem that the agenda in 2002, as it was in 1855, is to find a scientific/medical rationale for a culturally-derived impulse to circumcise male infants.

But why stop there? Think how much healthier the whole population would be if other troublesome body parts were amputated before they could get up to mischief. Mucous membranes seem to be a weak link in the body’s defences, so off with the lips for a start; and perhaps we could revive the painful nineteenth century practice of cauterising the urethra with silver nitrate so as to reduce susceptibility down there. Excising a lung would cut down the surface area of treacherous pulmonary mucosa by 50 per cent, thus reducing vulnerability to airborne infections like tuberculosis and bronchitis. Amputation of the right hand in all men at birth would do much to protect women from the slaps, punches and beatings they routinely receive from abusive fathers, husbands and lovers, and give them a greater chance of resisting rape.

One of the major sources of injury and disease in boys are cuts and fractures on the legs, arising from the fact that normal boys are born with two and are thus inclined to run about recklessly. Later they play rough sports and ride motorbikes, the accidents from which are a serious burden on the public health system. Jonathan Hutchinson’s own omission with respect to such excess risk should be lesson to us. One of his sons died as a result of tetanus caught from a graze on his leg sustained in a fall. Had he been the beneficiary of a thoughtful pre-emptive leg amputation in infancy he would not have been running around so promiscuously, would not have fallen over, would not have cut his leg and caught a fatal disease, and he might well have lived long enough to make contributions to medical knowledge and human happiness as great as those of his father.